Does Fragmented Care Result in Worse Outcomes for Patients With Bladder Cancer?

By Emily Menendez - January 23, 2023

Fragmented care (FC) occurs when patients with cancer receive care from multiple institutions, which can affect oncologic outcomes. Riveros et al sought to determine if care fragmentation impacts the outcomes of patients receiving neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). Treatment outcomes were compared between patients who received FC and those who received non-fragmented care (NFC).

The researchers used results from the National Cancer Database that featured adult patients with urothelial carcinoma of the bladder who had received NAC followed by RC between 2004 and 2017. The patient groups were divided into 2 arms: FC (defined as receiving NAC at a different facility from where RC was performed) or NFC (defined as receiving NAC and RC at a single facility).

The primary outcome of the study was overall survival (OS). Secondary outcomes included time from diagnosis to treatment (NAC and RC) and perioperative outcomes. Multivariable Cox regression analysis was performed to determine the relationship between FC and OS in the context of other relevant covariates, and Kaplan-Meier survival estimates were calculated after stratifying by type of care received.

The study enrolled a total of 2223 patients. Of those patients, 1035 (46.6%) had received FC and 1188 (53.4%) had received NFC. Patients with FC experienced a greater travel distance, higher comorbidity burden, and more often had their surgical treatment carried out at high-volume facilities. They also experienced a slightly longer median time to RC (160 vs 154 days, P=.001).

On Kaplan-Meier analysis, no differences in median OS were found between the FC and NFC groups. Multivariable Cox regression analysis showed the factors associated with worse OS included age, advanced tumor, node, metastasis stage, lymphovascular invasion, and positive surgical margins. However, FC was not associated with worse OS. On subgroup analysis, the researchers found that FC received at academic facilities and NFC received at high-volume centers were associated with lower rates of overall mortality.

The researchers concluded that FC is not associated with worse outcomes for patients with MIBC who receive NAC followed by RC. Both FC and NFC are seen as reliable treatment options for patients.